Through the Scope Removal and Resheath of a Lumen Apposing Metal Stent as Salvage Technique After Misdeployment During EUS-Guided Choledochoduodenostomy

• Published in: The American journal of gastroenterology Vol. 113; p. S967
• Main Authors: Sanchez-Yague, Andres, Lopez-Muñoz, Cristina, Irigoin, Robin Rivera, Cantos, Andres Sanchez
• Format: Journal Article
• Language: English
• Published: New York Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins 01.10.2018
• Subjects: Catheters; Gastroenterology; Stents
• ISSN: 0002-9270; 1572-0241

Introduction EUS-guided choledochoduodenostomy offers a less invasive option for the management of biliary obstruction due to pancreatic head tumor after failed ERCP or impossibility to reach the papilla. Lumen apposing metal stent (LAMS) deployment using electrocautery-enhanced catheters has decreased procedure times under one minute. Broader availability of this stents has shifted its use from highly specialized therapeutic endoscopists to others with minimal or no therapeutic experience. Although a relatively fast procedure, complications are common and management options are required. Case description We present the case of a 42-year-old patient with a non-resectable stage IV pancreatic head cancer presenting with cholangitis. The papilla was not accessible due to duodenal stricture. EUS-guided choledochoduodenostomy with an 8x8mm LAMS was performed using an electrocautery enhanced delivery cathether. Access was obtained using a free hand technique. Although the catheter appeared to be into the common bile duct (CBD) the distal flange deployed between the CBD and the duodenal wall. A guidewire was inserted and the partially deployed LAMS was removed over the wire through the scope. The stent was re-sheathed and advanced over the wire. The distal flange was deployed again between the CBD and the duodenal wall leading to the notion that the image of the guidewire into the CBD was a ghost image. The partially deployed stent was removed again over the wire and re-sheathed. Given the possibility of a ghost image we removed the guidewire and obtained access through a nearby point performing a successful delivery of the stent and creating the choledochoduodenostomy that drained pus abundantly. A perforation wasn't visible. The patient presented with mild discomfort after the procedure but no signs of perforation. Discussion Although EUS-guided choledochoduodenostomy with LAMS deployment using an electrocautery-enhanced catheter has greatly facilitated the technique broadening its use, possible complications should not be underestimated. This case highlights two practical tips: 1/ a guidewire should always be available and proficiency in over the wire exchanges is recommended; and 2/ a half deployed 6x8mm or 8x8mm LAMS using this delivery system can be safely removed through the scope. In our experience in bench models larger stents are prone to dislodge during removal obstructing the working channel.